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18 ROPES ST - BPA-11-587
The Commonwealth of Massachusetts Board of Building Regulations and Standards / Il Massachusetts State Building Code, 780 CMR, 7`h edition Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised One- or Two-Family Dwelling A ri115, 200.9 This Secti F Official Use Onl Building Permit Number: /f Da Applie / 1 Signature: - isofl, - lI Building Commissioner/I t B or o ui] s Date SECTIO 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1/14"/✓<", Lla Is this al accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system 13 CTION 2: PROPERTY OWNERSHIP' 2.1 Owne 'of ecord: [y ONNr/1- (<Ow�.Ar�-U PdtY�l MifhnQ u U �, - �' Name(P 'n Address for Service: s— � g7 �al 5�71 Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': i/ _ Z ?`�• SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials) Official Use Only, 1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier " x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ' 3 11 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) • /��' V// I-T License umber Expirati n Date Name fCHolde>)(1/A J� /ti�>rl �+ List CSL Type(see below) 'r A cess Type Description U Unrestricted(up to 35,000 Cu.FtJ Signature R Restricted 1&2 FamilyDwelling _:� M Mason Only VFa V RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 1 5.2Je�tered Home Im �/oQvesmeR t Contractor(HIC) -� ,oc lULf 17=r % C7�� H1C o a y N - e or BIC istrant Name Re istraf n Number Addr �0 0// Expiration Date Signa re Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... ❑ No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S N OR CONTRACTOR APPLIES FOR BUILDING PERMIT M c aQl u✓ a as Owner of the subject property hereby authorize to act on my behalf, in all matters re tk e t rk ut orized by this building permit application. Signature of Owner Date Sf CTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION Mio of Kvvidu I, as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. P 'nt i a- 0 /a Signature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) NOTES: L An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L. a 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I OR6 and 1 I O.RS,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" MOYNIHAN LUMBER OF BEVERLY, INC. "QUALITY BACKED BYA DESIRE TO PLEASE" 82 River Street P.O.Box 509 FEIN:04-2261995 Beveft MA 01915-0509 A A Contractor Reg No.: 978-927-0032 Exp. Date: Salesperson(s): HOMEOWNER INFORMATION iic✓i�r J Pi' alts (/ 3--50C, G/7-77-3— 3z/ ? Name Daytime Phone 18 Zf-.3/S IYY4 Street Add (Not P.O.Box) ening Phone �11�/t�c A4A n/92� City/Town State Zip Cade Mailing Address(it dMerent fran street Address) WORK TO BE PERFORMED AND MATERIALS TO BE USED Moynihan Lumber of Beverly, Inc.agrees to perform the work set forth in Exhibit A for Homeowner and to use such materials in connection therewith as set forth also in Exhibit A,attached hereto and made a part hereof. The following schedule shall sc adhered to unless cirFgmstances arise beyond Moynihan Lumber'Qf I� Beverly, Inc.'s control:Work uled to begin: / /_ Expected date of completion:/_/_ be based upon amval of order material TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE Moynihan Lumber of Beverly, Inc. agrees to erform t rk, and fumish the material and labor set forth in Exhibit A for the Total Contract Price of:$ 6 which amount includes all finance charges). Payment I$®made by Homeowner according to the following payment schedule: $ Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of one-third(1/3)of the Total Contract Price as set forth above;OR the Total Cost of Special/Custom O rs as et forth below). $ by—L–/ or upon completion of delivery of materials $ y_/_Lor upon completion o i alt $ pon completion of the Contract�� In order to meet the completion schedule set forth above,the following materials/equipment must be special ordered before the Contract work begins,for a Total Cost of Special/Custom Orders of$ $ to be paid for building permit $ to be paid for $ to be paid for QJIDAOT SIGN THIS CON RA T IF THERE ARE ANY BLANK SPACES '54- Moynihan Lumber of Bevedv.Inc. X7./29,/24/0 Homeowner's Signature VAI Lti Daft Contractor ate ;C6'1 gv ,lao 0 By�y ��j1A- Homeowner's Name(Printed) N (Printed)and Title of Signatory You may cancel this Contract N It has been signed by a party thereto at a place other than an address of Contractor,which may be Its main office or branch thereof,provided you notify Contractor in writing at Its main office or branch by ordinary mail posted, by telegram sent or by delivery,no later than midnight of the third business day following the signing of this Contract. See attached notice of cancellation for an explanation of this right 1057-BRr 4/09 white-Office Yellow-Sales'Semce Pink-Customer - Page 1 of 5 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.aov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumhers Applicant Information Please Print Legibly Name(Business/Organization/Individual):Eric Arserault Address: 24 Graham Street City/State/Zip: Leominster, Ma. 01453 Phone# 978-660-4860 Are you an employer? Check the appropriate box: Type of project(required): 1. _ 1 am an employer with 4. - I am a general contractor and I 6. - New Construction Employees(full and/or part-time)' have hired the sub-contractors .� Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Ship and have no employees These sub-contractors have 8• - Demolition Working for me in any capacity. workers'comp.insurance. 9. - Building Addition [No workers'comp.insurance 5. _ We are a corporation and its 10. - Electrical repairs or additions required.] officers have exercised their 3. - I am a homeowner doing all work right of exemption per MGL 11. - Plumbing repairs or additions myself. [No workers'comp: C. 152, '_1(4),and we have no 12. - Roof repairs insurance required.]H employees. [No workers' 13. - Other comp.insurance required] •Any applicant that checks box R1 must also fill am the section below showing their workers compensation policy information. k Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. Contractors that check this box must attach an additional sheet showing the fume of the sub-comracton and their workers' lam an employer that is providing workers'compensation Insurance for my employees. Below is the polity and job site information. Insurance Company Name: Tho TrayplprG Policy#or Self-ins.Lic.#: I6805583MS46 ExpirarionDate:08/j/%/ Job Site Address: For all FCCIP towns City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify,undo the pairs and pencallti.,es of perjury that the information provided above is true and carred. Signature: G _�/�--^—' /�— Date: Phone#: �b - iI bt7 a Official use only. Do not write in this area,to be completed by city of town official. City or Town: Permit/License#: Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: %homichusetts- Dep;ttimcnt of Puhlic S:d'eh - Iwo . Board of Buildin«Rc_ul:ttions and Construction Supervisor License License: CS 100210 Restrictedto: 00 ERIC ARSENAULT 24 GRAHAM ST LEOMINSTER, MA01453 - s c�lG_iy i Expiration: 112612011 .. ('..nmii"i,mer Tr=: 100210 Jle�amm�aoxeeald"o�✓G/maaduoelA Office of Consumer A[fairs&Business Regula5op HOME IMPROVEMENT CONTRACTOR Registration: Expiration; - 8/102011 Trg 287680 Type: .Partnership ARSENAULT BROS:CONSTRUCTION ERIC ARSENAULT - 24 GRAHAM ST. LEOMINSTER.MA 01453 Undersecretary i OP ID NB DATE(MMmDIYYYY) 1coJRD; CERTIFICATE OF LIABILITY INSURANCE � _2 Da 2s 10 ucER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION UCER , Bagley"6 Mayo ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE;DOES NOT AMEND,EXTEND OR urance Agency, Inc• . ; Box 360 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. chin Street, P. n . ..ainster MA 01453 NAIC# ine: 978-534-5133 Fax:978-534-9385 INSURERS AFFORDING COVERAGE , � INSURERA The Travelers Shawn Arsenault S INSURER B'. Eric Arse cult INSURER C. Ars na�ylt-Bros. Construction WSURER D24 Graham Street Leominster MA 01453 INSURER =RAGES .�POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE T THE POLICY PERIOD INDICATED.NOTWITHSTANDING O LADING . 'REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WRH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH ACIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. SR -_--__._TYPE.OFk.S!IRARCE-._. ___.. _ __.... POLICY NUMBS[Z_.,_.._OAT£rMNJDDII—PDATE.(4M/DD:.1-, _.._.__LINKS—_ EACH OCCURRENCE $1000000 GENERAL LIABILITY I s535000 $ COMMERCIAL GENERAL LIABILITY I6805583M546 OB/Ol/10 08/01/11 PREMISES Ed OCWrerWn CLAIMS MADE IKOCCUR PFRSOUL&ADe Person) $1000 PERSONALSADV INJURY 51000000 GENERAL AGGREGATE s2000000 PRODUCTS-COMP/OP AGG 52000000 GENL AGGREGATE LIMIT APPLIES PER I POLICY FITS El LOC NE I COMB AUTOMOBILE LIAn4TP/ I COMBINED SINGLE LIMIT �S CO Bnp ANY AUTO ALLOWNEDAUTOS - 80BILY INJURY S j (Per person) SCHEDULED Ay'TOS_ HIRED AUTOS1 BODILY INJURY S j I (Per scadent) NON-OWNED%UTOS PROPERTY DAMAGE S (Per accident) AUTO ONLY-EA ACCIDENT $ GARf,GE LN&LIT:' EAACC I S ANY AUTO _ OTHER THAN AUTO ONLY: AEG S EACH OCCURRENCE S E%CESSNMBRELL�A LIABILITY OCCUR IJ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION 5. WUbIAIq IV]" WORKERS COMPENSATJN AND -____. .._ .._ ._. _- -._.- -. TORYIJMITS ER -'EMPL.OYEfiS'LIABILITY I EL EACH ACCI6ENT 3 ANY PROPRIETORIPARTNEMEXECUTIVE E.L.DISEASE-EA EMPLOYEE $ OFFICERIMEMBER EXCLUDED? .t yes,desr+ibe wrier E.L DISEASE-POLICY LIMIT S BPECIAL PROVISIONS belov DTHER IPTION OF OPERATIOI:S:L=CATIONSI VEHICLESI EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS - i1FICATEHOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYSWRIII N NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER.ITS AGENTS OR Moynihan Lumber REPRESENTATIVES 82 River Street AUTHORIZED REPRESENTATIVE Beverly 2•SA 01915 Richard M. Ba le - - ©ACORD CORPORATION 1988 :D 25(2001108)